PN3 Final ASSESMENT 2023

1. The nurse, planning care for a mechanically ventilated client, would plan to administer pantoprazole. The nurse understands this medication is to prevent the onset of which of the following complications? Thrombophlebitis Hypertension Hyperglycemia Stress Ulcers 2. A client is diagnosed with cardiogenic shock. The nurse should plan immediate interventions to address which of the following complications of this disorder? Pulmonary Embolism Deep vein thrombosis Acute renal failure Disseminated intravascular coagulation 3. A patient in the emergency department is experiencing a hemorrhagic stroke. The nurse anticipates which of the following symptoms may have been present at the onset? SATA Vomiting Limited mobility worse in the morning Severe, sudden headache Increased appetite Change in mental status 4. A nurse is caring for an end-of-life terminally ill client, experiencing very shallow and rapid breathing with periods of apnea. After evaluating the client, which action by the nurse would be most appropriate? Reduce the number of people in the client's room Reorient the client as needed Place the client in supine position Elevate the clients HOB 5. A nurse is admitted to the hospital with an infected postoperative surgical wound. The practitioner orders vancomycin IV. Order: Vancomycin 1 gram in 500 ml dextrose 5% water (D5W) to infuse over 2 hours via infusion pump. Calculate the flow rate in ml/hr. 250 6. A nurse assesses a client who sustained a basal skull fracture and notes a thin stream of clear drainage coming from the client's right nostril. Which of the following actions should the nurse take first? Palpate the clients head for the presence of fractures Assess the drainage from eyes and ears Assess the drainage and test the drainage to rule out cerebral spinal fluid Ask the client to keep their head elevate 7. An emergency department nurse triages a client with diabetes mellitus who has fractured her wrist. Which action would the nurse take first? Remove the medical alert bracelet from the fractured arm Place the client in a supine position with a warm blanket Cover any open areas with a sterile dressing Immobilize the arm by splinting the fracture 8. A nurse cares for a client who has obstructive jaundice. The client asks, " Why is my skin so itchy?" How would the nurse respond? "Bile salts accumulate in the skin and cause the itching." "Toxins released from an inflamed gallbladder lead to itching." "Itching is caused by the release of calcium into the skin." "Itching is caused by a hypersensitivity reaction. 9. A nurse is caring for a client on mechanical ventilation and finds the client agitated and restless. What action by the nurse is most appropriate? Reassure the client that they are safe Restrain the clients' legs and arms Sedate the client immediately Assess the cause of the agitation 10. A nurse obtains the health history of a client with a fractured femur. Which factor identified in the client's history would the nurse recognize as an aspect that may delay healing? Osteoporosis Oral contraceptives Sedentary lifestyle Current smoking history 11. The nurse is notified that the clients monitor is showing artifact. What does the nurse do next? Troubleshoot the equipment Check the status of the client Monitor and document the artifact Notify the physician for orders 12. A nurse is monitoring a client who has an acute kidney injury. Which of the following laboratory findings should the nurse expect? Hypokalemia Metabolic acidosis Hypercalcemia Elevated BUN and creatinine 13. A client in the intensive care unit is scheduled for a lumbar puncture today. On assessment, the nurse finds the client breathing irregularly with one pupil fixed and dilated. Which of the following nursing actions is the best? Ensure that informed consent is on the chart. Document these findings in the client’s record. Give the prescribed preprocedural sedation. Call a rapid response team